Disease burden and unmet needs for prevention of venous thromboembolism in medically ill patients in Europe show underutilisation of preventive therapies

SummaryIt was the aim of this review to assess the incidence of venous thromboembolism (VTE) and current practice patterns for VTE prophylaxis among medical patients with acute illness in Europe. A literature search was conducted on the epidemiology and prophylaxis practices of VTE prevention among adult patients treated in-hospital for major medical conditions. A total of 21 studies with European information published between 1999 and April 2010 were retrieved. Among patients hospitalised for an acute medical illness, the incidence of VTE varied between 3.65% (symptomatic only over 10.9 days) and 14.9% (asymptomatic and symptomatic over 14 days). While clinical guidelines recommend pharmacologic VTE prophylaxis for patients admitted to hospital with an acute medical illness who are bedridden, clear identification of specific risk groups who would benefit from VTE prophylaxis is lacking. In the majority of studies retrieved, prophylaxis was under-used among medical inpatients; 21% to 62% of all patients admitted to the hospital for acute medical illnesses did not receive VTE prophylaxis. Furthermore, among patients who did receive prophylaxis, a considerable proportion received medication that was not in accord with guidelines due to short duration, suboptimal dose, or inappropriate type of prophylaxis. In most cases, the duration of VTE prophylaxis did not exceed hospital stay, the mean duration of which varied between 5 and 11 days. In conclusion, despite demonstrated efficacy and established guidelines supporting VTE prophylaxis, utilisation rates and treatment duration remain suboptimal, leaving medical patients at continued risk for VTE. Improved guideline adherence and effective care delivery among the medically ill are stressed.

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The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE): Venous Thromboembolism Prophylaxis Practices in Acutely Ill Medical Patients.

Blood ◽

10.1182/blood.v104.11.1762.1762 ◽

2004 ◽

Vol 104 (11) ◽

pp. 1762-1762 ◽

Cited By ~ 3

Author(s):

Victor F. Tapson ◽

Herve Decousus ◽

Jean-Fran[ccedi]ois Bergmann ◽

Beng H. Chong ◽

James B. Froehlich ◽

...

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Major Surgery ◽

Medical Illness ◽

Medical Patients ◽

Median Length ◽

Thromboembolism Prophylaxis ◽

Vte Prophylaxis ◽

Elastic Stockings

Abstract Background Despite consensus group recommendations indicating that medical patients should receive appropriate venous thromboembolism (VTE) prophylaxis, prophylaxis practices remain poorly characterized. This analysis of IMPROVE, a prospective study of acutely ill medical patients, describes in-hospital prophylaxis practices prior to the publication of updated VTE prevention guidelines by the American College of Chest Physicians. Methods Patient recruitment began in July 2002. Patients ≥18 years old, and hospitalized for ≥3 days with an acute medical illness are enrolled consecutively. Exclusion criteria are: therapeutic antithrombotics/thrombolytics at admission; major surgery or trauma during 3 months prior to admission; and VTE treatment begun within 24 hours of admission. Results Data were from 4315 patients (32% from USA) enrolled up to 30 June 2004 in 37 hospitals in 11 countries (76% with 3-month follow-up data). Patients are 50% female, median (IQR) age 69 (50–80) years, median length of hospital stay 8 (5–14) days, median weight 68 (58–80) kg, and 40% were immobile for ≥3 days (median length of immobility 7 [4–14] days, including immobility immediately prior to admission). In-hospital VTE prophylaxis was received by 41% of patients (Table 1). Of patients with no risk factors (44%), one risk factor (40%), or ≥2 risk factors (16%), 25%, 49%, and 67% received prophylaxis, respectively. 12% of IMPROVE patients would have been eligible for inclusion in the MEDENOX study. Of these, only 52% received prophylaxis in hospital. Prophylaxis was provided to 6% of patients during the 3-month follow-up period, and continued in 11% of patients after discharge. Conclusions Only 41% of IMPROVE patients received VTE prophylaxis, with considerable variation in types and regimens of prophylaxis used. While MEDENOX showed the benefits of VTE prophylaxis (enoxaparin 40 mg) in acutely ill medical patients, only half of MEDENOX-eligible patients received prophylaxis. Table 1. Use of in-hospital VTE prophylaxis (N=4315) VTE prophylaxis Patients receiving VTE prophylaxis, % ROW, rest of world; *Excluding elastic stockings and aspirin ≥1 type of VTE prophylaxis* 41 LMWH - USA (Q12h, Qd) 7 (5, 1) LMWH- ROW (Q12h, Qd) 31 (29, 2) UFH - USA (Q12h, Q8h) 28 (15, 11) UFH - ROW (Q12h, Q8h) 6 (5, 0) Intermittent pneumatic compression (USA, ROW) 6 (19, 0) Aspirin (USA, ROW) 4 (7, 3) Elastic stockings (USA, ROW) 6 (3, 8)

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Rates of Clinically Apparent Venous Thromboembolism and Death Resulting from Pulmonary Embolism among Unselected Hospitalized Acutely Ill Medical Patients Versus Rates Predicted from Clinical Studies.

Blood ◽

10.1182/blood.v106.11.1620.1620 ◽

2005 ◽

Vol 106 (11) ◽

pp. 1620-1620

Author(s):

Franco Piovella ◽

Frederick A. Anderson ◽

Hervé Decousus ◽

Gordon FitzGerald ◽

Jean-François Bergmann ◽

...

Keyword(s):

Venous Thromboembolism ◽

Clinical Studies ◽

Study Data ◽

Medical Illness ◽

Medical Patients ◽

Vte Prophylaxis ◽

Autopsy Series ◽

Unselected Sample ◽

Observational Cohort ◽

Hospital Deaths

Abstract Background Without evidence from autopsies, the majority of deaths resulting from pulmonary emboli (PE) are indistinguishable from deaths due to other cardiovascular diseases. This has led to a gap in perceptions between the benefits and risks of providing venous thromboembolism (VTE) prophylaxis. In this study, we estimated the incidence of clinically apparent VTE in hospitalized acutely ill medical patients in The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE), and compared this with the expected incidence derived from clinical studies that used autopsy or prospective venographic confirmation of clinically important VTE. Methods Beginning in July 2002, a consecutive, unselected sample of patients who were aged ≥18 years and hospitalized for ≥3 days with an acute medical illness, were enrolled in this observational cohort from 49 hospitals in 12 countries. Up to 31 March 2005, 6946 patients were enrolled. Results Based on autopsy series of all-cause in-hospital deaths reported in the literature, PE is associated with 10% of deaths, is the primary cause in 5%, and is clinically recognized as the primary cause in 1.5% of deaths. A review of clinical studies with mandatory venography resulted in predicted rates of 10% for all VTE and 1% for clinically recognized (confirmed) VTE. In IMPROVE, there were 4/291 (1.4%) deaths due to clinically recognized PE (vs. 4 predicted). There were 79 (1.1%) treated VTE events (vs. 69 predicted). Conclusions Observed rates of death due to PE and clinically recognized VTE in a real-world setting are consistent with predictions from clinical study data. Physicians should be aware of the significant gap that exists between clinically important and clinically evident VTE events. Reliance on the low rates of clinically recognized events to assess the seriousness of this disease can lead to a significant under-estimation of its impact on public health and a consequent failure to realize the proven benefits of VTE prophylaxis in hospitalized acutely ill medical patients.

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Venous Thromboembolism Prophylaxis in Acute Medically Ill Patients: A Retrospective Cohort Study

Blood ◽

10.1182/blood-2019-124495 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3678-3678

Author(s):

Anat Gafter-Gvili ◽

Genady Drozdinsky ◽

Oren Zusman ◽

Shiri Kushnir ◽

Leonard Leibovici

Keyword(s):

Internal Medicine ◽

Cohort Study ◽

Venous Thromboembolism ◽

High Risk ◽

Retrospective Cohort ◽

Medical Patients ◽

Vte Prophylaxis ◽

Medically Ill ◽

Pharmacologic Prophylaxis ◽

Medically Ill Patients

Background and Aims Venous thromboembolism (VTE) is considered as a preventable cause of death for hospitalized patients. Current guidelines recommend pharmacologic prophylaxis for medical patients considered high risk for VTE, despite failure of studies to show reduction in mortality. We aimed to assess the benefit and safety of VTE prophylaxis in acutely ill medical patients hospitalized in internal medicine wards. Methods Retrospective cohort study of all patients admitted to the internal medicine and acute geriatric departments, with an admission lasting more than 48 hours, during 2012-2018. Patients who received pharmacologic prophylaxis were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes were the 90 day incidence of pulmonary embolism (PE), symptomatic deep vein thrombosis (DVT), and major bleeding. Propensity-weighted logistic multivariable analysis was performed. Results A total of 18890 patient-unique episodes were included in the analysis. Of them 3206 (17%) received prophylaxis. A total of 1309 (6.9%) died. 540/1309 (41.3%) of those who received VTE prophylaxis died and 769/1309 (58.7%) of those who did not receive prophylaxis died. VTE Prophylaxis was not associated with a reduction in mortality, multivariate-adjusted OR 0.99 (95% CI 0.84-1.14). One hundred and forty two patients (0.7%) developed VTE. The frequency of VTE among patients who received VTE prophylaxis was 31% (44/142) compared with 69% (98/142) in patients who did not receive prophylaxis. The frequency of VTE in patients who had a Padua score ≥4 and received VTE prophylaxis, was 1.9% (30/1573) compared with 1.6% (44/2797) in those with a Padua score ≥4 who did not receive prophylaxis. 74/142 (52.1%) of patients with VTE had a Padua score ≥4, 44/1309 (1.4%) of those who received VTE prophylaxis and 98/15864 (0.6%) of those who did not. VTE Prophylaxis was not associated with reduction in VTE in the whole cohort, multivariable-adjusted OR 1.09 (95% CI 0.52-2.29). VTE prophylaxis was associated with an increase in major bleeding (multivariable-adjusted OR 1.24, 95% CI 1.04-1.48) Conclusion The current practice of routinely administering VTE prophylaxis to medically ill patients considered at high risk for VTE, resulted in a high risk for bleeding a without clear clinical benefit, and should be reassessed. Disclosures No relevant conflicts of interest to declare.

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Minor Depression: A Review of the Literature

The International Journal of Psychiatry in Medicine ◽

10.2190/ac30-p715-y4td-j7d2 ◽

1996 ◽

Vol 26 (2) ◽

pp. 177-209 ◽

Cited By ~ 52

Author(s):

David A. Beck ◽

Harold G. Koenig

Keyword(s):

Depressive Symptoms ◽

Depressive Disorders ◽

Medical Illness ◽

Central Feature ◽

Minor Depression ◽

Medical Patients ◽

Significant Group ◽

Atypical Depression ◽

Medically Ill ◽

Medical Inpatients

Objective: The clinical experience of the authors has suggested there is a significant group of elderly and individuals with medical illness and depressive symptoms who do not meet DSM-IV criteria for major depression. We were interested in all available data regarding minor depression in both the medically ill and community individuals. Methods: MEDLINE was searched from 1965 to 1995, using the terms “depressive disorders” and “medical illness,” as well as “atypical depression” and “elderly.” Relevant references from these primary articles were also utilized. Results: In medical patients, depressive symptoms were associated with decreased likelihood of discharge to home. Although diagnostic criteria vary, some suggest anhedonia as the central feature. From 3 to 16 percent of medical outpatients suffer from minor depression. Up to 64 percent of medical inpatients will complain of depressed mood. Studies in community samples found that minor depression was responsible for 9 to 16 percent of total disability days, and was associated with absenteeism from work, as well as separation and divorce. Little is known about the natural history and prognosis of minor depression. Conclusions: Minor depression is both common and has a significant impact on the health care system, and therefore deserves further study.

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Prevention of Venous Thromboembolism in Medically Ill Patients: Global and Individual Adherences Adjust to Risk Groups

Blood ◽

10.1182/blood.v112.11.4061.4061 ◽

2008 ◽

Vol 112 (11) ◽

pp. 4061-4061

Author(s):

Beatriz Grand ◽

Jorge Orosco ◽

Roberto Cacchione ◽

Patricio Duarte ◽

Dardo Riveros

Keyword(s):

Venous Thromboembolism ◽

High Risk ◽

Risk Group ◽

Risk Groups ◽

Individual Risk ◽

Medical Patients ◽

Medically Ill ◽

Mechanical Methods ◽

Correct Application ◽

Medically Ill Patients

Abstract Introduction: Venous thromboembolism (VTE) is an important problem for medical patients. In spite of the existence of evidence-based guidelines for prevention of VTE, prophylaxis for venous thromboembolism is underutilized. Objective: To assess the global and individual adherences (adjust to risk groups) to venous thromboembolism prophylaxis guidelines (VTEPG) in medical ill patients. Desing: Prospective observational study. Setting: The 50-bed medical floors of a university hospital. Material and Methods: Patients: All consecutively medically ill patients (pt) admitted during a 6-month period (n: 452). VTEPG: the guide divided medical patients in risk groups (G); G1: No need of VTEP (35 pt); G2: myocardial infarction (9 pt); G3: Stroke (21 pt); G4: high risk with thrombophilia, previous VTE, cancer (113pt); G5: respiratory and congestive heart failure, pulmonary infection (137 pt); G6: trauma (5 pt); G7: not included in previous groups, required an individual evaluation to asses VTE risk (112pt). Prophylaxis methods included: low dose unfractionated heparin (UFH) or low molecular weight heparin (enoxaparin 40 mg/d) and mechanical methods. Main outcome measurements: 1- Global: correct application of the guide (defined by a coincidence between the prophylaxis received and the recommendation); 2-Adjust to risk group. Results: Global adherence: Correct application of the guide was noted in 252 pts (56%); Adjust to risk group: GR1:71%; GR2:44%; GR3:62%; GR4:76%; GR5:55%; GR6:60% and GR7:26%. Conclusion: In our experience in medical patients global adherence to guides was 56%, the best adherence was observed in high risk groups 76% and the lowest 26% in those patients that need an individual risk assessment. This study and follow up permitted us to detect inaccurate prophylaxis uses and take corrective measures.

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Contemporary approach to primary prophylaxis of venous thromboembolism regarding the impact of risk factors on anticoagulation therapy duration

Srpski arhiv za celokupno lekarstvo ◽

10.2298/sarh1404249a ◽

2014 ◽

Vol 142 (3-4) ◽

pp. 249-256

Author(s):

Nebojsa Antonijevic ◽

Ljubica Jovanovic ◽

Valentina Djordjevic ◽

Ivana Zivkovic ◽

Miodrag Vukcevic ◽

...

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Venous Thromboembolism ◽

Anticoagulation Therapy ◽

Chronic Obstructive ◽

Medical Illness ◽

Medical Patients ◽

Class Iii ◽

Vte Prophylaxis ◽

The Impact

Adequate thromboprophylaxis primarily requires timely detection of reversible and irreversible risk factors of venous thromboembolism (VTE) and their categorization. It is important to note that the highest percentage of VTE episodes occur in non-surgical (medical) patients and that VTE develops in a large number of surgical patients upon hospital discharge; this emphasizes the need for adequate VTE prevention in inflammatory diseases, acute medical illness and other medical diseases as well as for prolonging and optimizing the anticoagulant regimen after surgical intervention in the primary VTE prophylaxis. As almost completely unrecognized and neglected major risk factors of VTE in clinical practice, we particularly point out the chronic obstructive pulmonary disease (COPD) and heart failure, especially in NYHA functional class III and IV patients with significantly reduced left heart ventricle. It is necessary to raise clinicians? awareness of a potential danger from wrongly and one-sidedly interpreted dyspnea and coughing signs in patients with COPD as typical symptoms of basic respiratory disease as well as from ascribing the signs of disease aggravation in heart failure patients exclusively to cardial status worsening, neglecting the possibility of having unrecognized and untreated pulmonary embolism at issue. Contemporary way of life enhances the development of new VTE risk factors such as traveler?s thrombosis, in particular during long-haul flights as well as in individuals sitting at a computer for prolonged periods (e-thrombosis). Determining and recognizing VTE risk factors, especially those formerly neglected nonsurgical ones and simultaneous presence of multiple risk factors within a given period is required for defining an adequate anticoagulant regimen in primary VTE prophylaxis for surgical and non-surgical (medical) patients.

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Scoring Systems for Estimating Risk of Venous Thromboembolism in Hospitalized Medical Patients

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0036-1597901 ◽

2017 ◽

Vol 43 (05) ◽

pp. 460-468 ◽

Cited By ~ 10

Author(s):

Paolo Prandoni ◽

Sofia Barbar

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Scoring Systems ◽

Cost Effective ◽

Assessment Model ◽

Medical Patients ◽

Thrombotic Risk ◽

Vte Prophylaxis ◽

Vein Thrombosis ◽

Medical Inpatients

AbstractDeep vein thrombosis and pulmonary embolism are associated with considerable morbidity and mortality in hospitalized patients, accounting for up to 10% of hospitalization-related deaths in both surgical and medical patients. Pharmacologic thromboprophylaxis has been demonstrated to be effective, safe, and cost-effective in preventing hospital-acquired venous thromboembolism (VTE) among medical inpatients, and clinician awareness of thrombotic risk promotes prescription of thromboprophylaxis. Guidelines recommend stratification of thrombotic risk for all patients and, unless contraindicated, administration of VTE prophylaxis. Based on several recognized predisposing and exposing risk factors for VTE, several scoring systems have been published in the past 15 years. Borrowing models developed in the surgical setting, recognized risk factors for VTE complications in medical inpatients have been combined in different weighted scores and derived and validated in heterogeneous medical populations. Although the perfect score, balancing thrombotic and hemorrhagic risk, has probably not yet been built, the adoption of an easy-to-use risk assessment model has the potential to support physicians in properly stratifying VTE risk in medical inpatients, tailoring thromboprophylaxis prescription.

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Venous Thromboembolism Prophylaxis Practices in Acutely Ill Medical Patients with Either Previous Cancer or Currently Active Cancer: Findings from IMPROVE.

Blood ◽

10.1182/blood.v104.11.1767.1767 ◽

2004 ◽

Vol 104 (11) ◽

pp. 1767-1767

Author(s):

Beng H. Chong ◽

Ajay K. Kakkar ◽

Victor F. Tapson ◽

Gordon Fitzgerald ◽

Frederick A. Anderson ◽

...

Keyword(s):

Venous Thromboembolism ◽

Cancer Patients ◽

Major Surgery ◽

Medical Illness ◽

Medical Patients ◽

Vte Prophylaxis ◽

Increased Risk ◽

Pharmacologic Prophylaxis ◽

To Receive ◽

Active Cancer

Abstract Background Patients with previous or current cancer have an increased risk for venous thromboembolism (VTE). However, little data is available on physician’s practices for providing VTE prophylaxis to these patients. The aim of this analysis of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) was to characterize VTE prophylaxis practices in acutely ill hospitalized medical patients who had previous cancer or currently active cancer. Methods Patient recruitment began in July 2002. Patients ≥18 years old and hospitalized for ≥3 days with an acute medical illness are enrolled consecutively. Exclusion criteria are: therapeutic antithrombotic agents or thrombolytics at admission, major surgery or trauma during 3 months prior to admission, and VTE treatment within 24 hours of admission. Results Data were from 4315 patients enrolled up to 30 June 2004 in 37 hospitals in 11 countries. 578 (13%) patients had currently active cancer (6% as the primary admission diagnosis). Patients with current cancer, previous cancer only, and no cancer were: 40%, 54% and 51% female, median (IQR) ages 72 (60–79), 77 (64–82) and 66 (47–80) years, median length of hospital stay 9 (5–18), 8 (5–12) and 8 (5–14) days, median duration of immobility 8 (5–19), 5 (4–11) and 6 (4–14) days (including immobility immediately prior to hospital admission). The percentages of patients with current or no cancer who received any pharmacologic prophylaxis were similar (see Table 1). However, aspirin was less likely to be prescribed, and intermittent pneumatic compression (IPC) more likely to be used in patients with current cancer than in those without cancer. Patients with previous cancer were more likely to receive pharmacologic prophylaxis, with increased use of unfractionated heparin (UFH) and aspirin, compared with patients without cancer. Conclusions Despite acutely ill medical patients with previous or current cancer having a higher risk for VTE, less than half received VTE prophylaxis, reflecting poor awareness of the benefits of prophylaxis. Physician’s perceptions of bleeding risks in cancer patients may influence prophylaxis practices; patients with current cancer were less likely to receive aspirin, but more likely to receive IPC, than patients without cancer. However, patients with previous cancer were more likely to receive pharmacologic prophylaxis than those without cancer, reflecting recognition by some physicians that these patients have an increased risk for VTE. Table 1. VTE prophylaxis in acutely ill medical patients with current, previous or no cancer VTE prophylaxis Current cancer (%) n=578 Previous cancer (%) n=266 No cancer (%) n=3471 *P<0.05, **P<0.01, ***P<0.001 (compared with patients with no cancer); †Some patients received >1 type of prophylaxis; ‡Without concomitant pharmacologic prophylaxis; ES, elastic stockings LMWH 24 24 23 UFH 10 21*** 13 Aspirin 1** 9** 4 Warfarin 0 1 1 Any pharmacologic prophylaxis† 34 46** 37 IPC‡ 7* 5 4 ES‡ 2 3 2

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Factors at Admission That Are Predictive of Increased In-Hospital Bleeding in Acutely Ill Medical Patients: Findings from the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE).

Blood ◽

10.1182/blood.v106.11.264.264 ◽

2005 ◽

Vol 106 (11) ◽

pp. 264-264

Author(s):

Hervé Decousus ◽

Rainer B. Zotz ◽

Victor F. Tapson ◽

Beng H. Chong ◽

James B. Froehlich ◽

...

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Univariate Analysis ◽

Medical Illness ◽

Medical Patients ◽

Vte Prophylaxis ◽

Risk Of Bleeding ◽

Increased Risk ◽

Significant Difference ◽

Clinically Significant

Abstract Background Although clinical studies have not shown a significant difference between the risk of bleeding in acutely ill medical patients receiving pharmacologic venous thromboembolism (VTE) prophylaxis and those receiving placebo, fear of bleeding may lead physicians to withhold pharmacologic prophylaxis for patients who should receive it. We therefore aimed to determine the incidence of, and risk factors for in-hospital bleeding in hospitalized acutely ill medical patients in IMPROVE, an international, observational registry. Methods Patients aged ≥18 years, hospitalized ≥3 days with an acute medical illness have been enrolled consecutively since July 2002. Exclusion criteria: therapeutic antithrombotics/thrombolytics at admission, major surgery or trauma during 3 months prior to admission, and VTE treatment within 24 hours of admission. Patients bleeding immediately before, or at admission were excluded from this analysis. Factors present at admission and associated with increased risk of in-hospital bleeding (defined as major or clinically significant nonmajor [Büller et al. N Engl J Med2003;349:1695–702]) were identified by univariate analysis (p<0.15) and included in a multiple logistic regression model (significant at p<0.05). The model was adjusted for patients’ length of stay in hospital. Results Data were from 5960 patients enrolled up to 31 March 2005 in 49 hospitals (12 countries). In-hospital bleeding occurred in 170 (2.9%) patients: 68 (1.1%) major and 102 (1.7%) clinically significant nonmajor bleeding. Independent risk factors for in-hospital bleeding are shown in the Table. In-hospital prophylaxis with low-molecular-weight and unfractionated heparin were not independently associated with an increased risk of bleeding when added to the analysis (p=0.51 and 0.38, respectively). In patients with 0, 1, 2 or ≥3 of these risk factors, the incidences of major in-hospital bleeding were 0.1%, 0.4%, 1.2% and 5.2%, respectively. Conclusions In this unselected patient population, the rate of major in-hospital bleeding was low (1.1%) and similar to that in the MEDENOX study (1.0%), a major clinical study of VTE prophylaxis. Factors that we identified will be valuable for predicting the risk of in-hospital bleeding in acutely ill medical patients. Table. Factors predictive of an increased risk of in-hospital bleeding in acutely ill medical patients Factor Odds ratio 95% confidence interval Active gastroduodenal ulcer 5.38 2.90–10.00 Bleeding disorder 4.54 2.02–10.19 Hepatic failure 3.34 1.80–6.19 Serum creatinine >1.5 mg/dL 2.29 1.63-3.21 Current cancer 2.08 1.43-3.03 Central venous catheter 2.00 1.31-3.05 ICU/CCU stay 1.92 1.23-3.02 Immobile ≥ 4 days 1.75 1.24-2.46 Ischemic heart disease 1.57 1.02-2.40

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Influence of Perceived Risk Factors for Bleeding on Venous Thromboembolism Prophylaxis Practices in Acutely Ill Medical Patients: Findings from IMPROVE.

Blood ◽

10.1182/blood.v106.11.917.917 ◽

2005 ◽

Vol 106 (11) ◽

pp. 917-917

Author(s):

Manuel Monreal ◽

Rainer B. Zotz ◽

Hervé Decousus ◽

Beng H. Chong ◽

Geno Merli ◽

...

Keyword(s):

Risk Factors ◽

Platelet Count ◽

Venous Thromboembolism ◽

Hepatic Failure ◽

Perceived Risk ◽

Medical Illness ◽

Cumulative Number ◽

Medical Patients ◽

Vte Prophylaxis ◽

Pharmacologic Prophylaxis

Abstract Background Acutely ill medical patients at risk for venous thromboembolism (VTE) should receive VTE prophylaxis. However, factors perceived by physicians to increase patients’ risk of bleeding may influence VTE prophylaxis practices. In this analysis from The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE), we examined whether perceived risk factors for bleeding had a significant influence on physicians’ prescribing of in-hospital prophylaxis in acutely ill medical patients. Methods Patients aged ≥18 years and hospitalized ≥3 days with an acute medical illness have been enrolled consecutively since July 2002. Risk factors considered were: severe renal failure, known bleeding disorder, hemorrhagic stroke, thrombocytopenia, bacterial endocarditis, active gastroduodenal ulcer, NSAID use, hepatic failure, age, immobility and alcoholism. Factors associated with different prescription rates of prophylaxis compared with rates in patients without these factors were identified and included in a multiple logistic regression model (significance at p<0.05). Results Up to 31 March 2005, 6946 patients were enrolled in 49 hospitals in 12 countries. Pharmacologic prophylaxis was received by 42%, 25%, 16%, and 14% of patients with a platelet count at admission >100, 50–100, 20–50 and <20x109/L, respectively (p<0.0001), and 43%, 39%, 30% and 32% of patients with none, 1, 2 and 3 risk factors for bleeding (p<0.0001). Factors independently associated with a lower/higher prescription rate of heparin-based prophylaxis compared with the risk in patients without these factors are shown in the Table. Conclusions The likelihood that hospitalized acutely ill medical patients receive in-hospital pharmacologic prophylaxis decreases as their platelet count at admission decreases, or their cumulative number of perceived risk factors for bleeding increases. Further studies are needed to determine whether the changes in prophylaxis practices observed in this study are justified. Table. Factors Independently Associated with a Higher/lower Rate of Heparin-based VTE Prophylaxis Factor Odds Ratio 95% Confidence Interval Age (per 10-year increase) 1.19 1.66–1.22 Immobility (per 10-day increase) 1.03 1.02–1.05 Alcoholism 0.62 0.46–0.83 Thrombocytopenia 0.60 0.48–0.74 Active duodenal ulcer 0.36 0.26–0.52 Hepatic failure 0.34 0.21–0.54

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